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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - Permit No. ------ �. <br /> ;Complete in Triplicate) <br /> _. This Permit Expires 1 Year From Date Issued Date Issued . __.___-.---_- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereir <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----------- CENSUS TRACT - 5 _7 <br /> Owner's Name W-• fel - -----Phone ----...- --- -- ----------------- <br /> _ Address .. ...17 '45/ ---- <br /> .C� ------------------------------ ------ - ------------- <br /> - Y <br /> Contractor's Name ----Elt, � � �`"` —ld -- --.-.License # Phone ------------------------ <br /> Installation will serve: Residence [ Apartment House❑ Commercial [-]Trailer Court ;❑ <br /> Motel ❑ Other ---------------- ---------- <br /> Number of living units:------- Number of bedrooms ._ -------Garbage Grinder _--__ Lot Size ___ ____.___.___.__._ =___.__-__- <br /> Water Supply: Public System and name _ __-._____ _ -------------------------------- ------------ ----Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan jX Adobe ❑ Fill Material ------- If yes, type ------___--_-_.- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------- __ _ Liquid Depth _ _-----____--.._____- <br /> Capacity -------------------- Type --------- --------- Material.--------------------- No. Compartments ------------------ <br /> Distance to nearest: Well -_____-__---_--____________.__Foundation ____-__.__--_-...__ Prop. Line ------------.__-_-__ J <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length - .-__- --------- _t: <br /> 'D' Box ------------ Type Filter Material -----------------Depth Filter Material ----.______________________--_._._____-- � <br /> Distance to nearest: Well _ __ _._-___ Foundation __ .........._ . Property Line .___._.______________ <br /> SEEPAGE PIT [ ] Depth ..........---------. Diameter --------------- Number __________-..- -- Rock Filled Yes ❑ No L <br /> Water Table Depth --------------------------- ------ ------------Rock Size --- -------------------------- <br /> Distance <br /> - - -------------------- <br /> Distance to nearest: Well _..--------------------..._.__________Foundation ---. ------------ Prop. Line ______________________ -� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------________-_------ ----- ------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) - ------------- --------------- --------------------------------------------------- -------------- ------- -- ------ <br /> Disposal Field (Specify Requirements) _r _ ---- I __ -----_--- ------------- <br /> - -- ------------------------- ------------------------------------------------------ ----------------------------------- ------- -------- -- -- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquir. <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _ Owner <br /> By .. - •sv a 1 ... -- Title f `-` � -c --- ---------------------------- <br /> (If other than owner) <br /> FOR `DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY:--- ------------------------- ----- --- ---------------------------- <br /> - ---------------------- DATE ` � 3 ------------ <br /> - <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------•- ----------------------------------------------------DATE -------------•-----------•-•----------•--- <br /> ADDITIONALCOMMENTS ----------------------•-••---•--------- ------------------- -----------------------------------------------------•-••-------------- -----------•---_---------- <br /> -- ------- -- - - ---- -----------•----------------------------------- ------------•--------------------------------------------------------------------------------------------------------- <br /> - -------- - -------------------•----------------------------- -----------------•------ --------------------------------------•------------------------------- ------------------- <br /> ---- -- - ------ <br /> Final Inspection by: - --- - --------- Date ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />